Health Savings Account $5000 Deductible

Choice Plus 2W4 /NO
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2015 - 12/31/2015
Coverage for: Employee/Family | Plan Type: POS
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or
plan document at www.welcometouhc.com or by calling 1-866-673-6293.
Important
Questions
What is the overall
deductible?
Are there other
deductibles for
specific services?
Is there an
out-of-pocket limit
on my expenses?
What is not included
in the out-of-pocket
limit?
Is there an overall
annual limit on what
the plan pays?
Does this plan use a
network of
providers?
Do I need a referral
to see a specialist?
Are there services
this plan does not
cover?
Answers
Why this Matters:
Network: $5,000 Indiv / $10,000 Family
Non-Network: $5,000 Indiv / $10,000
Family
Per calendar year. Does not apply to services
listed below as "No Charge".
No.
You must pay all the costs up to the deductible amount before this plan begins to
pay for covered services you use. Check your policy or plan document to see when
the deductible starts over (usually, but not always, January 1st). See the chart
starting on page 2 for how much you pay for covered services after you meet the
deductible.
You don’t have to meet deductibles for specific services, but see the chart starting
on page 2 for other costs for services this plan covers.
Yes, Network: $6,000 Indiv / $12,000 Family
Non-Network: $10,000 Indiv / $20,000
Family
Premiums, balance-billed charges, health care this
plan doesn’t cover and penalties for failure to
obtain pre-authorization for services.
No.
The out-of-pocket limit is the most you could pay during a coverage period
(usually one year) for your share of the cost of covered services. This limit helps
you plan for health care expenses.
Even though you pay these expenses, they don’t count toward the out-of-pocket
limit.
Yes. For a list of network providers, see
www.welcometouhc.com or call
1-866-673-6293.
If you use an in-network doctor or other health care provider, this plan will pay
some or all of the costs of covered services. Be aware, your in-network doctor or
hospital may use an out-of-network provider for some services. Plans use the term
in-network, preferred, or participating for providers in their network. See the
chart starting on page 2 for how this plan pays different kinds of providers.
You can see the specialist you choose without permission from this plan.
No.
Yes.
The chart starting on page 2 describes any limits on what the plan will pay for specific
covered services, such as office visits.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or
plan document for additional information about excluded services.
Questions: Call 1-866-673-6293 or visit us at www.welcometouhc.com. If you aren’t clear about any of the
underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or
www.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.
2W4
Page 1 of 8
Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
Coinsurance isyour share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the
plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you
haven’t met your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a
health care
provider’s office
or clinic
If you have a test
Services You May Need Your Cost If
You Use a
Network
Provider
Primary care visit to treat an 0% co-ins, after
injury or illness
ded
Your Cost If
You Use a
Non-Network
Provider
30% co-ins, after
ded
Specialist visit
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
None
30% co-ins, after
ded
30% co-ins, after
ded
None
0% co-ins, after
ded
Other practitioner office visit 0% co-ins, after
ded
Preventive
No Charge
care/screening/immunization
Diagnostic test (x-ray, blood 0% co-ins, after
work)
ded
Imaging (CT/PET scans,
0% co-ins, after
MRIs)
ded
Page 2 of 8
Limitations & Exceptions
None
Cost Share applies for only Manipulative (Chiropractic) Services.
Includes preventive health services specified in the health care
reform law.
None
Common
Medical Event
Services You May Need Your Cost If
You Use a
Network
Provider
If you need drugs Tier 1 - Your Lowest-Cost
Retail: $10 copay,
to treat your
Option
after ded
illness or
Mail-Order: $25
condition
copay, after ded
Specialty Drugs:
More information
$10 copay, after
about prescription
ded
drug coverage is
Tier 2 - Your Midrange-Cost Retail: $35 copay,
available at www.
Option
after ded
welcometouhc.com.
Mail-Order:
$87.50 copay,
after ded
Specialty Drugs:
$100 copay, after
ded
Tier 3 - Your Highest-Cost
Retail: $60 copay,
Option
after ded
Mail-Order: $150
copay, after ded
Specialty Drugs:
$300 copay, after
ded
Tier 4 (if applicable) Not Applicable
Additional High-Cost
Options
Your Cost If
You Use a
Non-Network
Provider
Retail: $10 copay,
after ded
Specialty Drugs:
$10 copay, after
ded
If you have
Facility fee (e.g., ambulatory
outpatient surgery surgery center)
Physician/surgeon fees
0% co-ins, after
ded
0% co-ins, after
ded
0% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
0% co-ins, after
ded
Pre-Authorization required for certain services for non-network
or benefit reduces to 50% of allowed.
None
0% co-ins, after
ded
0% co-ins, after
ded
Network Deductible applies.
If you need
immediate
medical attention
Emergency room services
Emergency medical
transportation
Retail: $35 copay,
after ded
Specialty Drugs:
$100 copay, after
ded
Limitations & Exceptions
Provider means pharmacy for purposes of this section.
Retail: Up to a 31 day supply.
Mail-Order: Up to a 90 day supply.
Copay is per prescription order up to the day supply limit listed
above.
You may need to obtain certain drugs, including certain specialty
drugs, from a pharmacy designated by us.
Certain drugs may have a Pre-Authorization requirement or may
result in a higher cost.
You may be required to use a lower-cost drug(s) prior to
benefits under your policy being available for certain prescribed
drugs.
See the website listed for information on drugs covered by your
plan. Not all drugs are covered.
Tier 1 contraceptives are covered at No Charge.
Retail: $60 copay,
after ded
Specialty Drugs:
$300 copay, after
ded
Not Applicable
Page 3 of 8
Network Deductible applies.
Common
Medical Event
Services You May Need Your Cost If
You Use a
Network
Provider
Urgent care
0% co-ins, after
ded
If you have a
Facility fee (e.g., hospital
0% co-ins, after
hospital stay
room)
ded
Physician/surgeon fees
0% co-ins, after
ded
If you have mental Mental/Behavioral health
0% co-ins, after
health, behavioral outpatient services
ded
health, or
substance abuse
needs
Mental/Behavioral health
0% co-ins, after
inpatient services
ded
Substance use disorder
0% co-ins, after
outpatient services
ded
Substance use disorder
0% co-ins, after
inpatient services
ded
If you are
Prenatal and postnatal care
No Charge
pregnant
Delivery and all inpatient
0% co-ins, after
services
ded
If you need help
Home health care
0% co-ins, after
recovering or have
ded
other special
health needs
Rehabilitation services
0% co-ins, after
ded
Habilitative services
0% co-ins, after
ded
Skilled nursing care
0% co-ins, after
ded
Your Cost If
You Use a
Non-Network
Provider
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
Limitations & Exceptions
None
Pre-Authorization required for non-network or benefit reduces
to 50% of allowed.
None
Pre-Authorization required for certain services for non-network
or benefit reduces to 50% of allowed.
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
Pre-Authorization required for non-network or benefit reduces
to 50% of allowed.
Pre-Authorization required for certain services for non-network
or benefit reduces to 50% of allowed.
Pre-Authorization required for non-network or benefit reduces
to 50% of allowed.
None
30% co-ins, after
ded
30% co-ins, after
ded
30% co-ins, after
ded
Limits per policy period: Physical, Occupational, Pulmonary 20
visits. Speech unlimited. Cardiac 36 visits.
Services provided under and limits are combined with
Rehabilitation services above.
Limited to 60 days per policy period (combined with Inpatient
Rehabilitation).
Pre-Authorization required for non-network or benefit reduces
to 50% of allowed.
Page 4 of 8
Inpatient Authorization may apply.
Limited to 60 visits per policy period.
Pre-Authorization required for non-network or benefit reduces
to 50% of allowed.
Common
Medical Event
Services You May Need Your Cost If
You Use a
Network
Provider
Durable medical equipment 0% co-ins, after
ded
Your Cost If
You Use a
Non-Network
Provider
30% co-ins, after
ded
Hospice service
30% co-ins, after
ded
30% co-ins, after
ded
Not Covered
Not Covered
If your child needs Eye exam
dental or eye care
Glasses
Dental check-up
0% co-ins, after
ded
0% co-ins, after
ded
Not Covered
Not Covered
Limitations & Exceptions
Covers 1 per type of DME (including repair/replace) every 3
years.
Pre-Authorization required for non-network DME over $1,000
or no coverage.
Inpatient Pre-Authorization required for non-network or
benefit reduces to 50% of allowed.
Limited to 1 exam every 2 years.
No coverage for Glasses.
No coverage for Dental check-up.
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)
Acupuncture
Bariatric surgery
Cosmetic surgery
Dental care (Adult/Child)
Glasses
Infertility treatment
Long-term care
Non-emergency care when
traveling outside the U.S.
Private-duty nursing
Routine foot care
Weight loss programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these
services.)
Chiropractic care
Hearing aids
Routine eye care (Adult)
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay
while covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-866-747-1019. You may also contact your state insurance department, the
U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272)or www.dol.gov/ebsa, or the U.S. Department of Health
and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact us at 1-866-673-6293 ; or the Employee Benefits Security Administration at 1-866-444-EBSA
(3272) or www.dol.gov/ebsa/healthreform or the Missouri Department of Insurance at 1-800-726-7390 or insurance.mo.gov. Additionally, a consumer
assistance program can help you file your appeal. Contact Missouri Department of Insurance at 1-800-726-7390 or visit www.insurance.mo.gov.
Page 5 of 8
Does this Coverage Provide Minimum Essential Coverage?
The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does
provide minimum essential coverage.
Does this Coverage Meet the Minimum Value Standard?
The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This
health coverage does meet the minimum value standard for the benefits it provides.
Language Access Services:
Spanish (Espa ol): Para obtener asistencia en Espa ol, llame al 1-866-673-6293
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-673-6293
Chinese
1-866-673-6293
Navajo (Dine): Dinek ehgo shika at ohwol ninisingo, kwiijigo holne 1-866-673-6293
To see examples of how this plan might cover costs for a sample medical situation, see the next page.
Page 6 of 8
Choice Plus 2W4 /NO
Coverage Period: 01/01/2015 - 12/31/2015
Coverage for: Employee/Family | Plan Type: POS
Coverage Examples
About these Coverage
Examples:
These examples show how this plan might
cover medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
See the next page for
important information
about these examples.
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
Amount owed to providers: $5,400
Plan pays $320
Patient pays $5,080
Amount owed to providers: $7,540
Plan pays $2,320
Patient pays $5,220
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Hospital charges (baby)
Anesthesia
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive
Total
Sample care costs:
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
Page 7 of 8
$5,000
$20
$0
$200
$5,220
Prescriptions
Medical Equipment and
Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive
Total
$2,900
$1,300
$700
$300
$100
$100
$5,400
Patient pays:
Deductibles
Copays
Coinsurance
Limits or exclusions
Total
$5,000
$40
$0
$40
$5,080
Choice Plus 2W4 /NO
Coverage Examples
Coverage Period: 01/01/2015 - 12/31/2015
Coverage for: Employee/Family | Plan Type: POS
Questions and answers about the Coverage Examples:
What are some of the
assumptions behind the
Coverage Examples?
Costs don’t include premiums.
Sample care costs are based on national
averages supplied by the U.S. Department
of Health and Human Services, and aren’t
specific to a particular geographic area or
health plan.
The patient’s condition was not an
excluded or preexisting condition.
All services and treatments started and
ended in the same coverage period.
There are no other medical expenses for
any member covered under this plan.
Out-of-pocket expenses are based only on
treating the condition in the example.
The patient received all care from
in-network providers. If the patient had
received care from out-of-network
providers, costs would have been higher.
If other than individual coverage, the
Patient Pays amount may be more.
What does a Coverage Example
show?
Can I use Coverage Examples to
compare plans?
For each treatment situation, the Coverage
Example helps you see how deductibles,
copayments, and coinsurance can add up. It
also helps you see what expenses might be left
up to you to pay because the service or
treatment isn’t covered or payment is limited.
Does the Coverage Example
predict my own care needs?
Yes . When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When
you compare plans, check the "Patient Pays"
box in each example. The smaller that
number, the more coverage the plan
provides.
Are there other costs I should
consider when comparing plans?
No . Treatments shown are just examples.
The care you would receive for this
condition could be different based on your
doctor’s advice, your age, how serious your
condition is, and many other factors.
Does the Coverage Example
predict my future expenses?
No . Coverage Examples are not cost
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on the
care you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Questions: Call 1-866-673-6293 or visit us at www.welcometouhc.com. If you aren’t clear about any of the
underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov or
www.dol.gov/ebsa/healthreform or call 1-866-487-2365 to request a copy.
2W4
Page 8 of 8
Yes . An important cost is the premium
you pay. Generally, the lower your
premium, the more you’ll pay in
out-of-pocket costs, such as copayments,
deductibles, and coinsurance. You should
also consider contributions to accounts such
as health savings accounts (HSAs), flexible
spending arrangements (FSAs) or health
reimbursement accounts (HRAs) that help
you pay out-of-pocket expenses.

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